The Blog

"My Therapist Talks Too Much"

Nowadays you
hear a lot of about the “patient-centered care model” in medicine.
The Institute of Medicine defines it as “Providing care that is
respectful of and responsive to individual patient preferences, needs, and
values, and ensuring that patient values guide all clinical decisions.”
This model emphases educated decision-making guided by the physician, and
is a shift away from the patriarchal “doctor knows best” model of
traditional medicine. It is the direction medicine is going.
Interestingly, it is the model that has been taught to psychologists for
decades. We have known for a long time that this basic model helps most
patients (not all) feel empowered and often strengthens the doctor-patient
relationship. It is based on mutual respect and joint decision-making.
But you’ll notice that the definition assumes this relationship is
between two people, when usually it is a “menage a trois,” where the third
party is the insurance company (and it’s just as sexy as it sounds.)

The
insurance company is the other decision-maker and often the most powerful voice
in the room. The insurance company often makes decisions about what care
you should receive and whether your provider should be paid. This
relationship is not consistent with the patient-centered model. Insurance
companies don’t base their decision on your values or your wishes, there is
often no discussion or dialogue between the insurance company and you or the
professional. They seem to make their decisions capriciously, motivated
by a desire to delay payment as long as possible to increase profits, or
judgments are based on biblical, opaque rulebooks that constantly change and
that health professionals can’t possibly memorize. You and your
professional, be it a physician or psychologist, may have a great plan on which
you both agree, but the insurance company may choose to nix it. Bizarrely, this sometimes happens after the service
was provided so the professional doesn’t get paid.

As if this
wasn’t frustrating enough, this unwanted three-way also can put the
professional in the awkward position of trying to be both patriarchal and
patient-centered. The enlightened health professional may have a
patient-centered approach, and may ask you to help make decisions about your
care (for example, how often you would like to meet for psychotherapy), yet the
professional may then need to act like a patriarch to satisfy the insurance
company. And the insurer is the alpha-wolf, the final arbiter of what treatment
should or shouldn’t be paid for. The insurer doesn’t want to hear about
the patient’s decision, or that the professional deferred to the values or
wishes of the patient, the insurer wants to hear that it was the professional’s
decision, based on clear medical (always medical, not psychological by the way)
necessity. In other words, the insurer expects the professional to be the
sole expert and decision maker, and has no real interest in what the patient thinks
he/she needs. The reason for this is that the insurer’s job (aside from
making massive profits) is ostensibly to cut costs. Relationships with their
customers based on mutual respect and dialogue make it harder for them to
say “no, you don’t need that MRI. There’s a perfectly good
radiation-soaking CT machine right there. No, not there, not where you
are–across town–we won’t pay for that one. And don’t even ask about
arranging transportation from us, that’s not our problem.”

The patient-centered model is a great idea, and the
Affordable Care Act certainly embraces it. But there is still this
glaring inconsistency where insurers are concerned. If we’re really going
to adopt this model, we have to go all the way. Insurers need to be regulated such that they are required
to strongly consider the wishes of their customers and respect the plans that patients
have with their health professionals. But, alas, we’re not going to see that
change, because it might increase costs. So what we’re left with is this
contradictory situation where the practice of medicine and psychology
follows one value system, but the payment for those services
follows another. The professional is given the added job of trying to
negotiate these opposing value systems, and the patient suffers the
disappointment that comes from being led to believe healthcare is
patient-centered, when in fact it is not.